On departure, the MARSOUIN maintained satisfactory intact transverse stability characteristics; however, the weight of additional fittings together with the unmonitored accumulation of working material reduced the mean freeboard and caused a slight trim which lowered the freeboard at the stern. Review of all the factors contributing to the lowered freeboard characteristics shows that the biology research gear, and related mast and rigging, accounted for about 20per cent of the total reduction, and the remaining portion was due to the weight of the additional fuel, outfit, spares and supplementary equipment. The primary means of access to, and escape from, the wheel-house is by way of an athwartships sliding door located in the after bulkhead, which slides to starboard when in the open position. When the vessel capsized to starboard, the door remained open and the escape route remained available. However, had the vessel capsized to port, it is highly likely that the unsecured door would have slid to port into the closed position and either retarded or prevented the operator's escape from the enclosed wheel-house. When the vessel was recovered, both outboard-motor control levers were found to be in the fully forward position and the ignition/starting switch was at ON. According to the operating procedure, the motors can be started electrically only when their combined throttle and drive levers are in the vertical, NEUTRAL position. Initial hasty attempts to restart both outboard motors were unsuccessful. Subsequent attempts, when the second and third waves were shipped, became futile because the vessel's pronounced after trim resulted in the prolonged and deep submersion of both motors' exhaust gas back-pressure relief valve outlets. All small vessels of open construction employed in exposed or relatively rough waters are operated at some risk, being particularly vulnerable to swamping by taking seas over the gunwale. Prudent operation with regard to loading, freeboard, speed and orientation relative to the prevailing seas is essential for safety. Review of the vessel's stability at the time of the occurrence shows that the weight, trimming and free-surface effects of the water initially shipped and retained on the well deck reduced the after freeboard and virtually eliminated the vessel's initial transverse stability. While the vessel was in this highly vulnerable condition, the shipping of two or more relatively high waves caused the vessel to settle markedly, trim even more by the stern, lose all righting ability and capsize. The Ship Division of IML specifically addresses boat maintenance and repair, providing manuals and introductory guidance for the functioning of on-board equipment, but only limited on-the-water instruction to the various crews before departure. Consequently, the practical boat-handling abilities of the marine biologists and summer students who operate the small boats for the most part, are gained largely from on-the-job experience and augmented in some instances by on-shore instruction from the Institut maritime du Qubec (Rimouski). The scheduling, assignment and matching of equipment with particular vessels by the Technical Committee composed of senior marine biology research managers is focussed primarily on the conduct and timely completion of the research projects. The absence of specific knowledge of marine practices, or the guidance of accurately recorded technical data addressing the current status and physical limitations of IML's rather small boats, can lead to the mismatching of some vessels and their assigned tasks. No formal standing orders addressing vessel operational trim, loading or stability limitations are provided for the instruction and guidance of the small boat crews at IML, nor are there any formal emergency instructions regarding the reporting responsibilities of the operators in the event of a vessel or crew-related accident. Senior shore personnel of the Ship Division and the Technical Committee of IML were unaware of the existence of accident reporting regulations, and the capsizing was reported belatedly by the operator, following some inquiries to the Canadian Coast Guard (CCG) and Transport Canada Marine Safety.Analysis On departure, the MARSOUIN maintained satisfactory intact transverse stability characteristics; however, the weight of additional fittings together with the unmonitored accumulation of working material reduced the mean freeboard and caused a slight trim which lowered the freeboard at the stern. Review of all the factors contributing to the lowered freeboard characteristics shows that the biology research gear, and related mast and rigging, accounted for about 20per cent of the total reduction, and the remaining portion was due to the weight of the additional fuel, outfit, spares and supplementary equipment. The primary means of access to, and escape from, the wheel-house is by way of an athwartships sliding door located in the after bulkhead, which slides to starboard when in the open position. When the vessel capsized to starboard, the door remained open and the escape route remained available. However, had the vessel capsized to port, it is highly likely that the unsecured door would have slid to port into the closed position and either retarded or prevented the operator's escape from the enclosed wheel-house. When the vessel was recovered, both outboard-motor control levers were found to be in the fully forward position and the ignition/starting switch was at ON. According to the operating procedure, the motors can be started electrically only when their combined throttle and drive levers are in the vertical, NEUTRAL position. Initial hasty attempts to restart both outboard motors were unsuccessful. Subsequent attempts, when the second and third waves were shipped, became futile because the vessel's pronounced after trim resulted in the prolonged and deep submersion of both motors' exhaust gas back-pressure relief valve outlets. All small vessels of open construction employed in exposed or relatively rough waters are operated at some risk, being particularly vulnerable to swamping by taking seas over the gunwale. Prudent operation with regard to loading, freeboard, speed and orientation relative to the prevailing seas is essential for safety. Review of the vessel's stability at the time of the occurrence shows that the weight, trimming and free-surface effects of the water initially shipped and retained on the well deck reduced the after freeboard and virtually eliminated the vessel's initial transverse stability. While the vessel was in this highly vulnerable condition, the shipping of two or more relatively high waves caused the vessel to settle markedly, trim even more by the stern, lose all righting ability and capsize. The Ship Division of IML specifically addresses boat maintenance and repair, providing manuals and introductory guidance for the functioning of on-board equipment, but only limited on-the-water instruction to the various crews before departure. Consequently, the practical boat-handling abilities of the marine biologists and summer students who operate the small boats for the most part, are gained largely from on-the-job experience and augmented in some instances by on-shore instruction from the Institut maritime du Qubec (Rimouski). The scheduling, assignment and matching of equipment with particular vessels by the Technical Committee composed of senior marine biology research managers is focussed primarily on the conduct and timely completion of the research projects. The absence of specific knowledge of marine practices, or the guidance of accurately recorded technical data addressing the current status and physical limitations of IML's rather small boats, can lead to the mismatching of some vessels and their assigned tasks. No formal standing orders addressing vessel operational trim, loading or stability limitations are provided for the instruction and guidance of the small boat crews at IML, nor are there any formal emergency instructions regarding the reporting responsibilities of the operators in the event of a vessel or crew-related accident. Senior shore personnel of the Ship Division and the Technical Committee of IML were unaware of the existence of accident reporting regulations, and the capsizing was reported belatedly by the operator, following some inquiries to the Canadian Coast Guard (CCG) and Transport Canada Marine Safety. IML did not provide the operator with standing orders or formal instructions addressing the loading, freeboard, trim or weather-related operational limitations of the vessel. There was no formal monitoring system or assessment by a suitably qualified person of the loading, operational limitations, trim and stability of this small vessel, which was operated by uncertified personnel engaged in marine biology research projects. The cumulative effect of additional navigation equipment, deck and rigging fittings, extra fuel tanks, biology research equipment and spare gear reduced the as-designed freeboard and made the vessel more vulnerable to shipping seas over the gunwale and transom. The well deck was swamped when the vessel was manoeuvred astern into following seas that were three times the height of the effective transom freeboard. Intact transverse stability was satisfactory on departure; however, the vessel capsized when stability was lost because of the weight and free-surface effects of water shipped and retained on the well deck. The outboard motors stalled when their exhaust gas back-pressure relief valve outlets became deeply submerged as the vessel went astern into steep following seas. Prolonged submersion of the exhaust gas back- pressure relief valve outlets precluded restarting the outboard motors, while the vessel was partially swamped and heavily trimmed by the stern. Despite the relatively rough weather conditions observed before departure, no one on board wore a PFD, and because the lifebuoy and inflatable liferaft were secured to the wheel-house top, they could not float free after the capsizing. Shore IML management personnel were unaware of the existence of accident reporting regulations, and the occurrence was belatedly reported by the operator as a result of inquiries to the CCG and the Marine Safety Branch of Transport Canada.Findings IML did not provide the operator with standing orders or formal instructions addressing the loading, freeboard, trim or weather-related operational limitations of the vessel. There was no formal monitoring system or assessment by a suitably qualified person of the loading, operational limitations, trim and stability of this small vessel, which was operated by uncertified personnel engaged in marine biology research projects. The cumulative effect of additional navigation equipment, deck and rigging fittings, extra fuel tanks, biology research equipment and spare gear reduced the as-designed freeboard and made the vessel more vulnerable to shipping seas over the gunwale and transom. The well deck was swamped when the vessel was manoeuvred astern into following seas that were three times the height of the effective transom freeboard. Intact transverse stability was satisfactory on departure; however, the vessel capsized when stability was lost because of the weight and free-surface effects of water shipped and retained on the well deck. The outboard motors stalled when their exhaust gas back-pressure relief valve outlets became deeply submerged as the vessel went astern into steep following seas. Prolonged submersion of the exhaust gas back- pressure relief valve outlets precluded restarting the outboard motors, while the vessel was partially swamped and heavily trimmed by the stern. Despite the relatively rough weather conditions observed before departure, no one on board wore a PFD, and because the lifebuoy and inflatable liferaft were secured to the wheel-house top, they could not float free after the capsizing. Shore IML management personnel were unaware of the existence of accident reporting regulations, and the occurrence was belatedly reported by the operator as a result of inquiries to the CCG and the Marine Safety Branch of Transport Canada. The MARSOUIN was swamped while going astern into following seas, lost transverse stability and capsized because of the weight and free-surface effects of the water shipped and retained on the well deck. The weight of an accumulation of additional equipment, fuel oil, deck fittings and spare gear reduced the vessel's effective freeboard, making it more vulnerable to shipping seas over the gunwale and transom.Causes and Contributing Factors The MARSOUIN was swamped while going astern into following seas, lost transverse stability and capsized because of the weight and free-surface effects of the water shipped and retained on the well deck. The weight of an accumulation of additional equipment, fuel oil, deck fittings and spare gear reduced the vessel's effective freeboard, making it more vulnerable to shipping seas over the gunwale and transom. In order to improve the safety of small vessel users, Fisheries and Oceans has implemented a series of actions to correct the observed deficiencies: Implementation of a more severe monitoring system for small vessel users, including the presence of a coxwain in certain areas of operation. In collaboration with the Institut maritime du Qubec (Rimouski), development of an academic and hands-on training for small vessel users. Establishment of a sub-committee on occupational safety and health for small vessels to receive complaints and comments; and Implementation of an awareness and information program for users of small vessels.Safety Action In order to improve the safety of small vessel users, Fisheries and Oceans has implemented a series of actions to correct the observed deficiencies: Implementation of a more severe monitoring system for small vessel users, including the presence of a coxwain in certain areas of operation. In collaboration with the Institut maritime du Qubec (Rimouski), development of an academic and hands-on training for small vessel users. Establishment of a sub-committee on occupational safety and health for small vessels to receive complaints and comments; and Implementation of an awareness and information program for users of small vessels.